In nursing homes, hospitals or in private homes where invalid patients with certain diseases and afflictions are bedridden, a problem arises from bed sores which these patients develop. These bed sores or decubitus ulcers usually result from a loss of blood circulation caused by pressure on the skin, particularly pressure over a bony protuberance. The pressure on areas of support exceeds the mean capillary blood pressure and these areas are vulnerable to the decubitus ulcers. Other factors which can contribute to decubitus ulcers are lack of proper ventilation, moisture and diet. Additionally, the problem of bed wetting and the accumulation of urine in the bed contribute to the bed sores of the patient since the moisture remains in the area of the patient's body. There have been attempts to remedy these conditions and prevent the decubitus ulcers, but some of these have been relatively commercially unsuccessful. Some have involved merely the passing of air through the bed mattress which air is then allowed to pass upwardly around the patient's body. Other devices have had pulsatingly inflatable air mattresses which again merely allow the air to be circulated upwardly around the body of the patient. Some of the more acceptable devices useful in the treatment of bed sores are the Clinitron Therapy method provided by Support Systems International, Inc. of Charleston, South Carolina, and dental irrigating devices described in an article on pages 303-305 of the September/October 1984 Vol. 33, No. 5 issue of Nursing Research. Other devices to treat decubitus ulcers include whirlpools, air mattresses, heel and elbow sheepskin protectors, heat lamps, foot boards, and draw sheets. While some of these units have desirable characteristics, they also possess serious drawbacks. Some of the disadvantages of these devices are as follows: Whirlpools can lead to possible infection or reinfection unless a completely sterile environment is maintained. Air mattresses have caused pressure points in obese patients, heel and elbow protectors reduce friction but are found to be not as well padded in the areas needed most, and also may retain moisture, therefore promoting maceration. The Clinitron Flotation System is an excellent preventative measure, but is so expensive that most facilities only have one unit, or none at all, and is not practical since it cannot be moved up and down. Overhead trapeze bars can only be used by responsive patients. Heatlamps can cause severe burns if not watched intensely, and need to be used every eight hours.
Some supportive measures used to prevent decubiti are: occupational therapy, physical therapy, nutritional therapy, and tissue assessment on admission. Some physical measures used to prevent these pressure sores are as follows: a repositioning schedule every two hours, checking bony prominences for breakdown daily, keeping skin dry and clean, ambulating patient as much as possible, forcing fluids, and using cornstarch to prevent friction.
Decubitus ulcers are staged according to severity:
Stage I--Skin pink-mottled, the epidermis is damaged. PA0 Stage II--Skin is cracked, blistered and broken, the epidermis is destroyed. PA0 Stage III--Skin is broken with some tissue involvement. The sub-cutaneous skin is destroyed and there are decaying cells. PA0 Stage IV--Extensive penetration to muscle and bone, presence of necrotic tissue, and profuse drainage. Structures are decayed. By stage III or IV, debridement is usually necessary. PA0 1. Mikulic, M. A. Treatment of pressure ulcers. Am. J. Nurs. 80:1125-28, June, 1980. PA0 2. Love-Mignogna, S., and Wind, S. Decubitus ulcers and the Karaya treatment program. ONAJ. 5:17-18, Sept. 1978. PA0 3. Berecek, K. H. Treatment of decubitus ulcers. Nurs. Clin. North Am. 10:171-210, March 1975. PA0 4. Rhodes, B., and others. The treatment of pressure sores in geriatic patients: a trial of sterculia powder. Nurs. Times 75:365-368, Mar. 1, 1979. PA0 5. Kavchak-Keyes, M. A. Treating decubitus ulcers using four proven steps. Nurs. 77 77:44-45, Oct. 1977. PA0 6. Lee, B. Y., and others. Topical application of providone-iodine in the management of decubitus and stasis ulcers. J. Am. Geriatr. Soc. 27:307:306, July 1979. PA0 7. Hyland, D. B., and Kirkland, V. J. Infrared therapy for skin ulcers. Am. J. Nurs. 80:1800-1817, October 1980. PA0 8. Connel, J. F., and Rousselot, J. M. Povidineiodine extensive surgical evaluation of a new antiseptic agent. Am. J. Surg. 108:849-855, December 1964. PA0 9. Morely, M. 16 steps to better decubitus ulcer care. Can. Nurse 77:29-33, July-August, 1981. PA0 Boric acid: 17.50% ph 5.1 PA0 Hydrogen: 4.88% PA0 Oxygen: 77.62% PA0 Molecular wt.: 61.84% PA0 Abbreviation: H.sub.3 BO.sub.3 PA0 I. Wash: PA0 II. Wash: PA0 III. Wash: PA0 IV. Wash:
Discussions of decubitus ulcers and their treatment can be found in the following journal articles:
There are many different products available for the care of decubitus ulcers. Some of these are Betadine Solution Wash, Uniwash, Duoderm, Op-site, the Bard Absorption dressing, water repellent ointments, Dakins Solution as a wash, Elase, antacids, Deprisan as a medicated dressing and Domeboros Solution. Betadine solution rinses are good for their antibacterial properties, but some allergic reactions can occur to the iodine, enhancing the skin problem. Uniwash and Uniderm treatments have to be done every eight hours or more frequently. Dressings are necessary and beneficial but sometimes tear the skin further. Medicated dressings such as Silvadene have to be changed also every eight hours. Domeboros Solution is used every four hours during the day. Antacids may be beneficial for superficial ulcers, but can hold in purlent matter and debris in the deep ulcer.
Thus, decubitus ulcers, otherwise known as "bedsores", are an age old problem. Treatment is usually a uniform and standard nursing treatment in a facility, but prevention is the best cure. Although not all bedsores can be blamed on nursing care because many are not preventable, there are an estimated 3,000,000 pressure sores in the U.S.A. yearly. In 1983, an estimated $8,000,000,000.00 were spent on treating pressure sores.
Patients prone to these problems are cachetic patients (those in negative nitrogen balance), patients with congenital or acquired boney deformaties, stroke patients who are immobile, paraplegics with uncontrollable muscle spasms, any spinal cord injury patient, incontinent patients, arthritic patients, those who are confused or comatose, nutritionally deficited patients, those with edema or poor capillary refill, anyone who is on medications such as steroids, tranquilizers and analgesics, any geriatric patient, and anyone with pre-existing diseases.
These decubiti also result from friction, shearing force and pressure, which all hospital patients are exposed to while in bed. Usually, a combination of two of those forces will cause a pressure sore and it can happen in a twelve hour period. Friction can be from moving in bed, shearing can be from a position in bed, and pressure can be from gravity alone. A pressure of greater than 25 mm Hg. will occlude flow of blood to capillaries in soft tissues causing hypoxia and, if unrelieved, eventual necrosis.
Fluid filled beds alone cannot prevent pressure sores. The waterproof covering that encases the fluid in the bed does not allow moisture from the patient's skin to evaporate so mild to moderate sweating actually promotes friction when the patient moves. Preventative devices can only delay the development of pressure sores. Fluid filled beds cause hip flexion possibly leading to contractures and pooling of pelvic blood. Alternating pressure mattresses and gel flotation pads reduce pressure but not enough to maintain adequate blood flow to all capillaries.